1376653634 NPI number — DR. MIRZA W AHMED MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376653634 NPI number — DR. MIRZA W AHMED MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

AHMED

Provider First Name:

MIRZA

Provider Middle Name:

W

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1376653634

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/10/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

100 E LIBERY STREET

Provider Second Line Business Mailing Address:

SUITE 800

Provider Business Mailing Address City Name:

LOUISVILLE

Provider Business Mailing Address State Name:

KY

Provider Business Mailing Address Postal Code:

40202-1434

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

502-315-1458

Provider Business Mailing Address Fax Number:

502-479-1425

Provider First Line Business Practice Location Address:

1210 W 5TH ST

Provider Second Line Business Practice Location Address:

SUITE 100

Provider Business Practice Location Address City Name:

LONDON

Provider Business Practice Location Address State Name:

KY

Provider Business Practice Location Address Postal Code:

40741-2112

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

606-864-4040

Provider Business Practice Location Address Fax Number:

606-864-3500

Provider Enumeration Date:

08/30/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RC0000X , with the licence number:  31393 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RC0000X , with the licence number: 034761 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RI0011X , with the licence number: 31393 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 000715448AA , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 000715448AC , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 000715448AD , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 000715448AP , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 319761 . This is a "WELL CARE (MEDICAID CMO)" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 708612 . This is a "BCBS EDI #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 7100366800 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
• Identifier: 607859800 . This is a "DEPT OF LABOR #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: P00180131 . This is a "RAILROAD PROV #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 000715448AB , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".